Mistaken Identity

“Hey, save some pizza for me!” your resident exclaims as he joins the masses indulging in a late night treat from the ED administration. Over the past few months, the department’s “door-to-doc” times and “length-of-stay” times have improved enough to warrant a pizza party for the staff. “If all of you are stuffing your faces back here in the work room, who’s out there ensuring our metrics this month are going to be up to snuff?” you jest as you grab your third slice of cheesy goodness.

“It’s all good, Doc. I’ve got a quick case for you,” your enthusiastic intern states. “She’s in bed 10 and she’s all packaged up and ready for discharge. Her length-of-stay was definitely better than average!” In between bites of pizza, your intern summarizes the patient in bed 10 for you. She’s an otherwise healthy 42-year-old female who presents to the ED with right upper quadrant pain that started after dinner tonight. She’s been in town all weekend for a friend’s nuptials and thinks all of the eating and drinking is finally catching up with her. She denies any symptoms other than right upper quadrant (RUQ) and epigastric pain that has improved with some IV morphine that she received during her work-up. Her vital signs are normal, and her exam was only remarkable for RUQ tenderness to palpation. Your intern goes on to explain her differential for the patient’s presentation and expertly explains her reasoning for the work up that was initiated.

You review the results of the patient’s blood and urine tests and note that her CBC, CMP, and UA are within normal limits, and that her urine pregnancy test is negative. Your intern wheels over the ultrasound machine and pulls up the images she obtained at the bedside during her focused biliary scan. As the images are loading up, your intern states, “It’s all good. The wall of the gallbladder was a little thick, but there was no pericholecystic fluid, no sludge or gallstones, and the patient did not have a sonographic Murphy’s sign on exam.” She goes on to explain, “She has a bunch of stool and bowel gas that prevented me from getting a good subcostal or X-7 view, but the lateral approach worked just fine. Her common bile duct was normal and I didn’t see anything else that was concerning.”

You pull up the image where your intern measured the wall of the gallbladder, and this is what you see (top). You then have your intern pull up the images where she thought she saw stool and bowel gas (bottom).